Emergency Contact:

Employment Information of Insured

Primary Insurance Information

Secondary Insurance Information

Authorization for Release of Information and Assignment of Benefits:
I authorize the use of this signature on all insurance submissions and release of any and all medical records and/or financial information necessary to collect payment for medical services. I understand that my medical/financial information may be transmitted electronically via facsimile, Internet and/or text message. I also authorize and assign payment of medical or government benefits directly to Infectious Diseases Doctors, P.A. and/or physician on file, for the services provided to me. I understand that I am financially responsible for the charges not covered by my insurance policy.

To expedite your benefits confirmation, please upload a copy of the FRONT and BACK of your insurance card and the front of your government issued ID, then hit submit. You can use your cell phone to take the picture.

Immunizations

CONSENT FOR TREATMENT

I, as a patient/legal guardian, do consent for medical treatment by Infectious Disease Doctors, PA (ID DOCTORS, PA), physicians and nursing staff. This is inclusive of any treatment or procedure they deem medically necessary.

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

This is to serve as authorization to release medical information compiled in the course of medical treatment at ID DOCTORS, PA to the undersigned patient. A copy of this will serve as an original.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

ID DOCTORS, PA may use and disclose protected health information about me to carry out treatment, payment and healthcare operations. Please refer to ID DOCTORS, PA Notice of Privacy Practices for a more complete description of such uses and disclosures. 

I have the right to review the Notice of Privacy Practices prior to signing the consent. ID DOCTORS, PA reserves the right to revise at any time.

I acknowledge and agree that I have read ID DOCTORS, PA notice of privacy practices. I also understand that I will be given a copy of the notice if I ask for one.

PATIENT’S RESPONSIBILITIES

Patient is Responsible:

1. For providing accurate and complete information regarding his/her medical history.
2. For agreeing to a schedule of services and reporting any cancellation of scheduled appointments.
3. For participating in the development and updating of a plan of care.
4. For following the plan of care and clinical condition. For communicating whether he/she clearly understands the course of treatment and plan of care. For accepting responsibility for his/her actions if refusing treatment.
5. For timely reporting problems, changes in physical condition, re-hospitalizations, concerns or complaints.
6. Any replacement cost of lost/misused/damaged drugs/pumps or supplies will be responsibility of the patient and reimbursement that the patient seeks will be between the patient and his/her insurance company.
7. For fulfilling financial obligations for service.
8. For being responsible for picking up drugs and supplies from office during office hours.

FINANCIAL POLICY

1. Our physicians participate in a number of HMO and PPO networks. It is the patient’s responsibility to verify that the doctor is in or out of network.
2. If your insurance company requires a referral from your PCP, please have it sent to our office before your visit. We must have a referral on file before seeing you.
3. Payments are due at time of service & informing the office of any insurance changes in a timely manner. There will be a $25 charge for all returned checks.
4. We accept Medicare assignment and will bill Medicare for you. If you have any supplemental insurance, please bring this information with you to your appointment. You may be responsible for a portion of your charges if your
   secondary/supplement does not pay.
5. If you are being treated for a work-related injury (Worker’s Comp), we must have written approval from your adjustor prior to your appointment.
6. If treatment is sought due to a motor vehicle accident or other personal injury, you will be responsible for your bill, including office visits, radiology and labs. 

We must emphasize that as healthcare providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact the billing department promptly for assistance in the management of your account.

LIFETIME BENEFICIARY AUTHORIZATION FOR PERIOD OF THERAPY
I request that payment under any medical insurance program be made to ID Doctors, PA on any bills for services, supplies, equipment and/or medications furnished by ID Doctors, PA.
AGREEMENT TO PAY
I take responsibility and agree that I am responsible for payment for all supplies, medications, pumps, poles and services provided to me by ID Doctors, PA.
ASSIGNMENT OF BENEFITS
I hereby authorized ID Doctors, PA to request on my/our behalf and to collect directly all public and private insurance coverage benefits due for supplies, equipment, medications and services by ID Doctors, PA. In the event payments for
insurance benefits are made directly to any of the undersigned, the payee will endorse to ID Doctors, PA all checks for such payment.
RELEASE OF INFORMATION
The undersigned hereby authorize our insurer(s) and any other third party payer who provides patient with coverage to disclose to ID Doctors, PA any information that enables them to collect payment. Patient authorizes all medical personnel to
provide information to ID Doctors, PA concerning patient/client medical history, as it may relate to patient/client therapy. I allow the use of electronic transmission of medical/financial information including facsimile and email. The undersigned
consents to the review of patient/client records including medical records by and Federal, State, or Accrediting Body or Agency as required by the Regulatory, Licensing or Accrediting body. 

The undersigned certifies that he/she has read the foregoing and received a copy. The undersigned also certifies that he/she is the patient, or is duly authorized by the patient as patient’s general agent to execute and accept its items.

Notice of Privacy Practices for Infectious Disease Doctors, PA

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
This practices uses and disclosed health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive. This notice describes our privacy practices. You can request a copy of this notice at any time. For more information about this notice or our privacy practices and policies, please contact the Office Manager.

Treatment, Payment, Health Care Operations

Treatment
We are permitted to use and disclose your medical information to those involved in your treatment.

Payment
We are permitted to use or disclose your medical information to bill and collect payment for the services provide to you. For example, we may complete a claim form to obtain payment from your insurer or HMO. The form will contain medical information, such as a description of the medical service provided to you, that your insurer or HMO needs to approve payment to us.

Health Care Operations
We are permitted to use or disclose your medical information for the purposes of health care operations, which are activities that support this practice and ensure that quality care is delivered. 

Disclosures That Can Be Made Without Your Authorization 

There are situations in which we are permitted by law to disclose or use your medical information without your written authorization or an opportunity to object. In other situations we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization in writing, to stop future uses and disclosures. However, any revocation will not apply to disclosures or used already made or taken in reliance on that authorization.

Public Health, Abuse or Neglect, and Health Oversight
We may disclose your medical information for public health activities. Public health activities are mandated by federal, state or local government for the collection of information about disease, vital statistics (like births and death), or injury by a public health authority. We may disclose medical information, if authorized by law, to a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition. We may disclose your medical information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using.

We may also disclose medical information to a public agency authorized to receive reports of child abuse or neglect. Texas law requires physicians to report child abuse or neglect. Regulations also permit the disclosure of information to report abuse or neglect of elders or the disabled.

We may disclose your medical information to a health oversight agency for those activities authorized by law. Examples of these activities are audits, investigations, licensure applications and inspections which are all government activities  undertaken to monitor the health care delivery systems and compliance with other laws, such as civil rights laws.

Legal Proceedings and Law Enforcements
We may disclose your medical information in the course of judicial or administrative proceedings in response to an order of the court (or the administrative decision-maker) or other appropriate legal process. Certain requirements must be met before the information is disclosed. 

If asked by a law enforcement official, we may disclose your medical information under limited circumstances provided that the information:

• Is related pursuant to legal process, such as a warrant or subpoena;
• Pertains to a victim of crime and you are incapacitated;
• Pertains to a person who has dies under circumstance that may be related to criminal conduct;
• Is about a victim of crime and we are unable to obtain the person’s agreement;
• Is released because of a crime that has occurred on these premises; or
• Is released to locate a fugitive, missing person, or suspect.

We may also release information if we believe the disclosure is necessary to prevent or lessen an imminent threat to the health or safety of a person.

Worker’s Compensation
We may disclose your medical information as required by the Texas Worker’s Compensation law.

Inmates
If you are an inmate or under the custody of law enforcement, we may release your medical information to the correctional institution or law enforcement official. This release is permitted to allow the institution to provide you with medical care, to protect your health or the health and safety of others, or for the safety and security of the institution.

Military, National Security and Intelligence Activities, Protection of the President
We may disclose your medical information for specialized government functions such as separation or discharge from military services, requests as necessary by appropriate military command officers (if you are in the military), authorized national security and intelligence activities, as well as authorized activities for the provision of protective services for the President of the United States, other authorized government officials, or foreign heads of state.

Research, Organ Donation, Coroners, Medical Examiners, and Funeral Directors
When a research project and its privacy protections have been approved by an Institutional Review Board or privacy board, we may release medical information to researchers for research purposes. We may release medical information to organ procurement organizations for the purpose of facilitating organ, eye, or tissue donation if you are a donor. Also, we may release your medical information to a funeral director where such a disclosure is necessary for the director to carry out his duties.

Required by Law
We may release your medical information where the disclosure is required by law.

Your Rights Under Federal Privacy Regulations
The United States Department of Health and Human Services created regulations intended to protect patient privacy as required by the Health Insurance Portability and Accountability Act (HIPAA). Those regulations create several privileges that patients may exercise their HIPAA rights.

Requested Restrictions
You may request that we restrict or limit how your protected health information is used or disclosed for treatment, payment, or healthcare operations. We do NOT have to agree to this restriction, but if we do agree, we will comply with your request except under emergency circumstances.

To request a restriction, submit the following in writing: (a) The information to be restricted, (b) what kind of restriction you are requesting (i.e. on the use of information, disclosure of information of both), and (c) to whom the limits apply. Please send the request to the address and person listed below.

You may also request that we limit disclosure to family members, other relatives, or close personal friends that may or may not be involved in your care.

Receiving Confidential Communications by Alternative Means
You may request that we send communications of protected health information by alternative means or to an alternative location. This request must be made in writing to the person listed below. We are required to accommodate only reasonable requests. Please specify in your correspondence exactly how you want us to communicate with you and, if you are directing us to send it to a particular place, the contact/address information.

Inspection and Copies of Protected Health Information
You may inspect and/or copy health information that is within the designated record set, which is information that is used to make decisions about your care. Texas law requires that requests for copies be made in writing and we ask that requests for inspections of your health information also be made in writing. Please send your request to the person listed below.

We can refuse to provide some of the information you ask to inspect or ask to be copied if the information:

• Includes psychotherapy notes.
• Includes the identity of a person who provided information if it was obtained under a promise of confidentiality.
• Is subject to the Clinical Laboratory Improvements Amendments of 1988.
• Has been compiled in anticipation of litigation.

We can refuse to provide access to or copies of some information for other reasons, provided that we provide a review of our decision on your request. Another licensed health care provider who was not involved in the prior decision to deny access will make any such review.

HIPAA permits us to charge a reasonable cost based fee. The Texas State Board of Medical Examiners (TSBME) has set limits on fees for copies of medical records that under some circumstance may be lower than the charges permitted by HIPAA. In any event, the lower of the fee permitted by HIPAA or the fee permitted by the TSBME will be charged.

Amendment of Medical Information
You may request an amendment of your medical information in the designed record set. Any such request must be made in writing to the person listed below. We will respond within 60 days of your request. We may refuse to allow an amendment if the information:

• Wasn’t created by this practice or the physicians here in this practice.
• Is not part of the Designated Record Set
• Is not available for inspection because of an appropriate denial
• If the information is accurate and complete.

Even if we refuse to allow an amendment you are permitted to include a patient statement about the information at issue in your medical record. If we refuse to allow an amendment we will inform you in writing. If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we know have the incorrect information.

Accounting of Certain Disclosures
The HIPAA privacy regulations permit you to request, and us to provide, an accounting of disclosure that are other than for treatment, payment, health care operations, or made via an authorization signed by you or your representative. Please submit any request for an accounting to the person listed below. Your first accounting of disclosures (within a 12 month period) will be free. For additional requests within that period we are permitted to charge for the cost of providing the list. If there is a charge we will notify you and you may choose to withdraw or modify your request before any costs are incurred.

Appointment Reminders, Treatment Alternatives, and Other Health-related Benefits
We may contact you by telephone, mail or both to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you.

Complaints
If you are concerned that your privacy rights have been violated, you may contact the person listed below. You may also send a written complaint to the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint with the government or us. The contact information for the United States Department of Health and Human Services is:

U.S Department of Health and Human Services
HIPAA Complaint
7500 Security Blvd., C5-24-04
Baltimore, MD 21244

Our Promise to You
We are required by law and regulations to protect the privacy of your medical information, to provide you with this notice of our privacy practices with respect to protected health information, and to abide by the terms of the notice of privacy practices in effect.

Questions and Contact Person for Requests
If you have any questions or want to make a request pursuant to the rights described above, please contact:

Jabina Rajbhandary, Office Manager
PO Box 802772
Dallas, TX 75380
Phone: 972-484-7700
Fax: 972-484-7718

This notice is effective on the following date: September 19, 2012.

We may change our policies and this notice at any time and have those revised policies apply to all the protected health information we maintain. If or when we change our notice, we will post the new notice in the office where it can be seen.

INFECTIOUS DISEASE DOCTORS, P.A. INFORMED CONSENT FOR TELEHEALTH DURING THE CORONAVIRUS (COVID-19) PANDEMIC

This Informed Consent for Telehealth contains important information focusing on providing healthcare services using the PMD mobile application. Please read this carefully. When you sign this document, it will represent an agreement between yourself and ID Doctors, PA.

Benefits and Risks of Telehealth
Telehealth refers to providing consult services remotely using telecommunications technologies, such as video conferencing through the PMD app. One of the benefits of telehealth is that the patient and clinician can engage in services without being in the same physical location. This can be helpful particularly during the Coronavirus (COVID-19) pandemic in ensuring continuity of care as the patient and clinician likely are in different locations or are otherwise unable to continue to meet in person. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person treatment and telehealth, as well as some risks. For example:

• Risks to confidentiality. As telehealth consultations take place outside of the Infectious Disease Doctors, PA clinic there is potential for other people to overhear your consult if you are not in a private place during the consult. ID Doctors, PA will take reasonable steps to ensure your privacy. It is important; however, for you to make sure you find a private place for our consult where you will not be interrupted. It is also important for you to protect the privacy of our consult on your device. You should participate in the consult only while in a room or area where other people are not present and cannot overhear the conversation.
• Issues related to technology. There are many ways that technology issues might impact telehealth. For example, technology may stop working during a consult, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.

Electronic Communications
You may have to have certain computer or cell phone systems to use telehealth services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telehealth.

For communication between consults, ID Doctors will not discuss any clinical information by email or text and prefer that you do not either.

Treatment is most effective when clinical discussions occur at your scheduled consult. But if an urgent issue arises, you should contact the office by phone. If you are unable to reach the office and feel that you cannot wait for a returned call, and if you need immediate attention, contact your family physician or the nearest emergency room.

Confidentiality
ID Doctors, PA has a legal and ethical responsibility to make the best efforts to protect all communications that are a part of telehealth services. The nature of electronic communications technologies, however, is such that ID Doctors cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. ID Doctors will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telehealth consults and having passwords to protect the device you use for telehealth).

The extent of confidentiality and the exceptions to confidentiality that ID Doctors outlined in our Confidentiality Agreement for in person consults still apply in telehealth. Please let ID Doctors know if you have any questions about exceptions to confidentiality.

Appropriateness of Telehealth
ID Doctors will let you know if it is decided that telehealth is no longer the most appropriate form of treatment for you. If you decide telehealth is not optimal for you, it is important to let ID Doctors know.

Emergencies and Technology
Assessing and evaluating threats and other emergencies can be more difficult when conducting telehealth than in traditional in-person treatment.

If the consult is interrupted for any reason, such as technological connection failure, and you are having an emergency, do not call the physician back; instead, call 9-1-1, or go to your nearest emergency room. Call the physician back after you have called or obtained emergency services.

If the consult is interrupted and you are not having an emergency, disconnect from the consult and ID Doctors will wait two (2) minutes and then re-connect you via the PMD platform on which we agreed to conduct treatment. If ID Doctors does not connect via the telehealth platform within two (2) minutes, then call the office.

Fees
The same fee rates will apply for telehealth as apply for in-person therapy. Some insurers are waiving co-pays during this time. It is important that you contact your insurer to determine if there are applicable co-pays or fees which you are responsible for. Insurance or other managed care providers may not cover consults that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic consults, you will be solely responsible for the entire fee of the consult. Please contact your insurance company prior to our engaging in telehealth consults in order to determine whether these consults will be covered.

Records
The telehealth consults shall not be recorded in any way unless agreed to in writing by mutual consent. Your physician will maintain a record of telehealth consults in the same way they maintain records of in-person consults in accordance with ID Doctors policies.

Informed Consent
This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our treatment together and does not amend any of the terms of that agreement.

Your signature below indicates agreement with its terms and conditions.